A New Era in American Health Care

School of Nursing Dean Jean Johnson answers questions about the Affordable Care Act.

Jean Johnson, dean of the George Washington University School of Nursing, says it is time for the United States to address "the issue of people who are uninsured."

October 07, 2013

The new year will bring great changes to American health care.

Beginning Jan. 1, 2014, all Americans will be required to have health insurance under the Affordable Care Act, or “Obamacare” as it is commonly known. On Oct. 1, uninsured Americans had their first chance to sign up for health insurance via the online marketplace — despite efforts from Republicans in Congress to defund the law.

Last week, George Washington University School of Nursing Dean Jean Johnson participated on a panel at a National Journal event, "Countdown to Transformation," held 90 days before the Jan. 1 deadline. During the panel, titled “What the Affordable Care Act Means for Patients and Providers,” Dr. Johnson addressed questions about how the health care law could affect patients, doctors and nurses.

Dr. Johnson spoke with George Washington Today about these topics as well as what the Affordable Care Act means for GW students and employees.

Q: National Journal said Jan. 1, 2014, “could be the most significant day in the history of health care.” Do you agree with this statement? Is the Affordable Care Act going to significantly change health care delivery in the United States?

A: I don’t know if I would say it’s the most significant in health care history. Certainly the implementation of Medicare and Medicaid was really significant. But what happens Jan. 1 is that health insurance begins to kick in for the folks who are signing up through the health insurance exchanges. That will affect anywhere between 23 million and 40 million people. And that’s huge. The insurance exchanges really alter the landscape of how people get insurance, which has been employer-based for decades. Having individuals be able to access different plans and make choices is revolutionizing the health insurance industry. I think that it is time for this country to address the issue of people who are uninsured. To not provide a system of care to everyone in this country seems incredibly short sighted.

Q: What are some misunderstandings Americans have about the Affordable Care Act?

A: I think they’re confused about a number of different things. You’ll read in the newspaper and hear people being interviewed who say, “I don’t want government to be in my personal health care. But don’t touch my Medicare.” Do they understand that Medicare is a government program? There is also a misunderstanding in terms of some people supporting the Affordable Care Act who say they don’t support Obamacare.

But I don’t think any of the health agencies, as much as they have really tried, have made it understandable to the public. The health care law is very complicated. There are a lot of moving pieces. For the most part people want to know: Can I get insurance? What is it going to cost? Am I going to get any subsidies? And what will it cover?

Q: An estimated 32 million Americans will gain health insurance by 2019. What does that mean for nurse educators?

A: We have a responsibility to help students understand the Affordable Care Act, because they are going to be living with the effects of it. We are also trying to contribute to the primary care workforce by admitting more family nurse practitioners and adult gerontology nurse practitioner students. There are already not enough primary care providers, and rural areas are particularly underserved. As an example, in Virginia, 77 counties out of about 95 are designated primary care shortage areas.

The GW School of Nursing has created a strategy to address this shortage. Most of the nurses in underserved Virginia counties are associate-degree prepared. In order to get into a nurse practitioner program or a midwifery master’s program, you have to have a bachelor’s of science in nursing. We created an efficient and effective program to get those who have an associate’s degree into the B.S.N. program and then into the master’s program. We evaluate competency through use of matching the competencies with some of our B.S.N. upper division courses. Students can move into, for instance, the family nurse practitioner program, which is generally 48 credits, and only have to take 36. It’s a very streamlined way to get the associate degree nurses into the primary care workforce in underserved areas.

Q: Is the country’s health care system prepared to handle the influx of so many new patients? What role will nurses play in addressing the shortage of primary care doctors?

A: It’s critical for nurses to be able to practice to the full scope of their education and ability. The Institute of Medicine’s 2010 report on the future of nursing was very strong in its first recommendation that we need to break down the barriers to having advanced practice registered nurses practice to their full scope. And the National Governors Association has released a paper that recognized the importance of nurse practitioners in every state’s strategy addressing primary care needs. Nurse practitioners are really important providers in primary care.

Q: What are the most important facts GW faculty and staff should know about the Affordable Care Act?

A: Under the ACA, faculty and staff cannot be excluded from the plan at the university because of a pre-existing condition, and there is no cap on lifetime expenditures through the health insurance market, which are huge changes. Plus, there is a substantial number of health promotion/wellness provisions in the ACA law — people do not have to pay any additional out of pocket costs for immunizations, prenatal care and cancer screenings.

That doesn’t mean that insurance costs aren’t going to go up. But the cost of health care has been going up for decades. Trying to control the rate of increase has led to different attempts – HMOs in the ‘70s, DRGs in the ‘80s, competition in the ‘90s, value-based care in the 2000s. But one of the very important issues that have happened in the past 10 years is linking payment to outcomes.

Q: What about GW students? Under the ACA, children can stay under their parents’ health care plans until they are 26. But what about students whose parents are not insured? Will they buy insurance through the marketplace?

A: That’s one of the big questions. Will young, healthy people decide to pay the penalty or will they decide to buy health insurance? The insurance market is definitely hoping that young, healthy people will be buying into the insurance marketplace because that helps fund the entire pool of people. It’s a low-cost group, and they contribute to the premiums. It’s not clear what that group is going to do. It is likely that most students at GW probably will stay on their parents’ health insurance.

Staying on a parent’s plan is a relief for many younger people. Particularly with the economic downturn, it’s been tough for young people to get jobs that provide health insurance. Being uninsured is a problem, because accidents do happen, and major illnesses do happen. Not as often as in an older population, but they do happen.